Highlights of the NAASO 2005 Annual Scientific Meeting

Clinical Workshops

Five clinical workshops provided the opportunity to discuss current challenges and improve treatment strategies. One workshop addressed practical aspects of the diagnosis, assessment, and effective treatment of depressed obese adults and adolescents.^[4] This workshop was particularly helpful in presenting assessment tools and practical ways of identifying and dealing with the depressed patient. Of particular importance is the concept that depression is associated with weight gain, and special strategies must be implemented on an individual basis in order to be effective. Patient perceptions of becoming and being obese were also discussed. Special efforts need to be placed on the assessment and treatment of developing depression in adolescents, which may require innovative strategies that include structured environmental influences to encourage more positive thinking and behaviors.

Another workshop discussed the essentials to consider when setting up a weight-loss program, how to execute the team approach, and new considerations toward emphasizing weight maintenance.^[5] Because successful weight management depends on addressing the energy balance equation, both energy intake (diet) and energy expenditure (physical activity), along with individual modifying behavioral factors, need to be included in the successful weight management program. Thus, the importance of the office environment, structured support, and the interaction of an interdisciplinary team delivering common messages needs to be emphasized. Additional emphasis is being placed on weight maintenance and the prevention of weight gain/regain, with newer messages to help patients through difficult times. Longer-term follow-up and new treatment strategies are critical if the obesity epidemic is to be affected.

A workshop on bariatric surgery outlined preoperative and special assessment criteria, postbariatric dietary considerations, and nutritional status evaluation.^[6] The controversy of performing bariatric surgery in adolescents was discussed. Recommendations for adolescents included a body mass index (BMI) > 40 plus 1 serious comorbidity, or a BMI > 50 with a less serious comorbidity and the failure of nonsurgical treatment. Patients with a life-threatening comorbidity should be considered on a case-by-case basis.

A psychological evaluation is essential for all bariatric surgery candidates. Pre- and postoperative procedures, including compliance with dietary regimens, are becoming standardized. In order to manage nutrient deficiencies following bariatric surgery, patients need to take vitamin and mineral supplements for the rest of their lives. Recommended vitamins include a well-formulated multivitamin or a prenatal vitamin, and long-term evaluation of anemia (iron, ± 2, and folate) and thiamin deficiency should be emphasized. Special attention to calcium and vitamin D was recommended. Due to decreased food intake, achlorhydria, and gastrointestinal malabsorption, Robert Kushner, MD, Northwestern University, Chicago, Illinois, recommended that nutrition status be monitored by specific protocols to evaluate ferritin, calcium (PTH), and vitamin D (25[OH]D and 1,25[OH] D), along with alkaline phosphatase, folate, and vitamin ± 2. He also recommended routine complete blood count and chemistry profile, lipid profile, and hemoglobin A1C.^[7] Serial dual-energy x-ray absorptiometry measurements would also be helpful in assessing and monitoring bone health.

Bariatric surgery was emphasized by Walter Pories, MD, East Carolina University Brody School of Medicine, Greenville, North Carolina, as "the only effective treatment for severe obesity...with durable weight losses of greater than 100 pounds.^[8,9]" New directions with the lap band are being assessed; standards are being established; and the recognition of national centers of excellence has been recommended.

Office tools for the measurement of body composition and energy balance are becoming more available, user-friendly, and affordable. A workshop discussed the assessment of energy expenditure, including the measurement or calculation of resting metabolic rate and physical activity, energy (food) intake assessments, and useful office measures of body composition.^[10] Because personalized information and self-monitoring tools are powerful motivators for weight loss, the use of new technologies for indirect calorimetry, body composition (bioimpedance scales), and self-monitoring (food records and computerized programs) are being encouraged.

Another workshop emphasized recommendations for exercise vs physical activity and special considerations for managing obese adolescents.^[11] Small weight gains of 1-2 lb per year lead to overall larger cumulative weight gain and obesity over time. This gradual weight gain could be prevented by increases in physical activity of as little as 30 minutes/day at 5-8 kcal/minute (moderate to brisk walking) with attention to maintenance of this increase as a lifelong behavioral change. Adolescents are particularly sedentary and need to increase active playtime by substituting movement activities for video/computer time. Pedometers continue to be useful; an increase in steps per day is encouraged, but the target of 10,000 steps/day is the goal. Approximately 2000 steps are equal to 1 mile and approximately equivalent to 100 kcal.

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